Melanoma skin cancer can be fatal unless caught early, but most skin lesions are harmless. Dermoscopy with training can help with diagnosis. This blog is not a substitute for a medical opinion-if you are worried about a changing or funny looking mole or spot, get it checked by a doctor with suitable skills.

Autocorrected image. Does this show the features any better? Obviously you would not photoshop in features that weren’t there, but digitally editing for tone, brightness and contrast may help sometimes to see something that is there but subtle.

This has to be a BCC. Remember the 4 classic dermoscopic features of a BCC-pink colour, tightly focussed tapering tree-like (arborising) vessels, micro ulcers and irregular pigmented structures. You don’t often see all 4 features in any one lesion, but the features we see here are very pronounced. We see typical BCC vessels plus a group of irregular blue/grey globules on the right and a cluster of irregular pigmented structures around the perimeter from 8 o’clock to 2 o’clock. Typical BCC. The site, history, skin type and age group are all right for BCC as well, and there are no features of any other kind of lesion. A sound holistic diagnosis can be made.

PS the light oval structure at 5 o’clock is irrelevant. Most likely its a blocked pore, a common enough finding on the nose.

At this site, excision with the requisite 4mm margin will probably require a technically challenging reconstruction, e.g. a rotation or bi-lobed flap or else a skin graft. This means you need to be sure of the diagnosis before doing the procedure. The dermoscopic findings are sufficiently clear in this case to avoid the need for a pre-operative confirmatory biopsy, thus saving money and time.

Dermoscopy allows a confident diagnosis to be made of this nondescript lesion at a smaller stage. If the patient had been diagnosed a year later with this twice the size, he will still live as BCC’s don’t metastasise, but a larger procedure and bigger scar would be necessary. Dermoscopy is not useful only for melanomas, it allows facial BCs to be detected as a smaller size which reduces morbidity and treatment cost.

LEARNING POINT compare and contrast the vessels within the lesion with the vesels of the backround skin. Can you see the difference?